The Client with Foreign Body Aspiration
9. A child brought to the emergency department by his parents is diagnosed with a foreign body aspiration. Which of the following nursing diagnoses would the nurse identify as the priority for this child?
1. Ineffective Airway Clearance related to foreign body aspiration.
The child with a foreign body aspiration is experiencing an airway obstruction and requires immediate intervention to ensure adequate ventilation.
Therefore, the priority is Ineffective Airway Clearance.
2. Risk for Injury related to foreign body aspiration.
It may be important once the child's airway patency has been established.
3. Impaired Parenting related to foreign body aspiration.
It requires obtaining additional data about how the aspiration occurred.
4. Ineffective Health Maintenance related to foreign body aspiration.
10. The mother asks the nurse why peanuts are one of the worst things a child can aspirate. Which of the following would the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts?
1. They swell when wet.
Peanuts swell and become soft when moistened with bronchial secretions, making them difficult to remove.
2. They contain a fixed oil.
3. They decompose when wet.
4. They contain sodium.
Although peanuts contain a fixed oil that can cause lipoid pneumonia, begin to decompose when wet, and contain calcium, these factors do not make them particularly dangerous when aspirated.
11. After teaching the parents of a toddler about commonly aspirated foods, which of the following foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching?
1. Popcorn.
Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated.
2. Raw vegetables.
Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food.
3. Round candy.
It is often difficult to chew and comes in large pieces, making it easily aspirated.
4. Crackers.
Crackers, because they crumble and easily dissolve, are not commonly aspirated.
12. A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
1. Protest.
Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care.
Here, the child is fussing and crying and visibly pushes the nurse away.
2. Despair.
In the despair stage, the toddler becomes withdrawn and obviously depressed (eg, not engaging in play activities, sleeping more than usual).
3. Regression.
Regression is a return to a developmentally earlier phase because of stress or crisis (eg, a toddler who could feed himself before this event now is not doing so).
4. Detachment.
Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (eg, not reacting when the parents come to visit).
13. After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following?
1. Vomits.
Vomiting does not occur while a child is unable to breathe.
Once the object is dislodged, however, vomiting may occur.
2. Gasps.
Gasping, a sudden intake of air, indicates that the child is still able to inhale.
3. Gags.
When a child is choking, air is not being exchanged, so gagging will not occur.
4. Collapses.
The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse.